Patient History Form

Medical History

Family History

Social History



RESPONSIBLE PARTY - If responsible party is different from patient, this section must be completed.


Insurance Coverage - Primary

Conditions of Registration and Financial Policy

The following are our conditions of registration as well as our policies with respect to the billing and collections of your account. By signing below, you are agreeing to be bound by these terms.

Basic Policy:

Payment is due in full at the time service is provided in our office.

For Patients With Medicare:

We will bill Medicare on your behalf. As a courtesy, we will also bill secondary insurance carriers on your behalf. You are responsible for all co-insurance payments.

For Patients With Insurance:

All co-payments, coinsurances and deductibles are due at the time of service. As a policy we will collect $50 at the time of visit to cover a portion of any coinsurance or deductible that may be due as we cannot determine these actual amounts until the claim has processed by our insurance.  In the case where your insurance card/coverage stipulates a Copayment, we will collect the amount defined on your card which may be more or less than $50. We will bill insurance carriers on your behalf if we have a current contract with the carrier. After your insurance has processed the claim, we will be able to determine whether any refunds are due for overpayments towards copayment, coinsurance or deductible and those will be sent to the patient. Please be advised that your agreement with your insurance carrier is a private one and that ultimately, you are responsible for payment. If an insurance carrier has not paid a claim within 60 days of billing, our fees are due and payable from you. Our office will always strive to help you obtain the maximum possible coverage. It is, however, the patient's ultimate responsibility to determine the extent of coverage allowed by the insurance company.

In addition, preauthorization of a procedure is not a guarantee for payment. Any procedure may be considered not covered under the terms of your agreement with your insurance company. Your insurance carrier will make a determination of payment once the claim is received and reviewed . If after the claim is reviewed and it is determined by your insurance company that the procedure is not covered (cosmetic or not medically necessary), you will be financially responsible to Wilmington Dermatology Center, PLLC for the charges and will be billed for those services not covered by your insurance company.

Patients Who Have A Biopsy Performed In Our Office (Insurance & Self Pay):

A biopsy procedure may be performed in our office to assist in diagnosing your skin condition. Biopsies are submitted by Wilmington Dermatology Center (WDC) to a 3rd party board certified dermatopathology provider independent from WDC. The dermatopathology company evaluates the biopsy via microscope and returns a diagnostic interpretation. The act of evaluating your biopsy, performing any testing, and returning a report of their findings is directly billed by the pathology company to you or your insurance, not by WDC. We follow the approach approved by the American Academy of Dermatology for pathology billing, which eliminates any conflicts of interest and avoids any markups that would benefit the dermatologist if they billed for these external services.

Noncovered Services:

Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or immediately upon notice of insurance claim denial.

Missed Appointments:

In fairness to other patients and the doctor, we require at least 24 hours notice to cancel an appointment. You may be charged $50.00 for each appointment that was missed or not canceled with 24 hour notice. Missing more than two appointments without providing 24 hours notice is grounds for discharge from the practice.

Returned Checks:

There will be a fee of $25.00 charged by this office for each check returned to us by your bank.

Collection Agency Costs:

In the event your account is referred to a collection agency or attorney for collection, you agree to pay all collection fees, attorney fees, court costs, and expenses.


Notice of Privacy Practices

I hereby acknowledge that I had the opportunity to review the Notice of Privacy Practices of Wilmington Dermatology Center, PLLC. I understand that the Notice of Privacy Practices sets forth my rights relating to the use and disclosure of my personal health information and explains how Wilmington Dermatology Center, PLLC can use and/or disclose my personal health information both with and without my authorization. I understand that I am entitled to receive a copy of the Notice of Privacy Practices* if I so desire. I further understand that I may contact Dr. George if I have any questions regarding the contents of this Notice of Privacy Practices or to file a complaint about the privacy practices of Wilmington Dermatology Center, PLLC.

By signing I am providing my signature agreeing to authorizations and assignments defined above in the signature section for those areas checked.

(Reset Signature)

*A copy of our Notice of Privacy Practices can be found on our web site, here

Skin Care Questionnaire

Facial Goals:

Select your area(s) of concern and identify the location in the space provided .

Body Related Goals: Select your area(s) of concern and identify the location in the space provided .

Women's Health - Address Sexual Function / Urinary Incontinence through Collagen Stimulation